Special Initiative – Application Package Cover Sheet · Special Initiative – Application Package Cover Sheet Referring Agency: Please track all applications submitted and accepted

Special Initiative – Application Package Cover Sheet

Referring Agency:

Participant Name:

Select Applicant Barrier to employment and attach Agency letter: □ Foster Care □ Runaway □ ACS Preventive Services □ Homeless □ Offender/Justice Involved □ HRA – Business Link □ Homeless (In Shelter)

Please select the SYEP Provider this application will be submitted to: C.C.M.S - Community Counseling & Mediation St. Nicks Alliance Corp. Center for Alternative Sentencing and Employment Services The Children’s Aid Society Henry Street Settlement, Inc. United Activities Unlimited, Inc. La Guardia Community College- Research Foundation Wildcat Service Corporation Samuel Field YM & YWHA

Please list three (2) points of contact at your agency or individual case managers in the event there is a concern with the applicant: (List in the order of choice)

Name: Title:

Phone #: Email:

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Name: Title:

Phone #: Email:

________________________Note: If there are additional points of contact, please continue on the back of the page.---------------------------------------------

Are you aware of any issues that would prevent this applicant from being successful at the following sites?

Childcare Retail Other: Please explain below

Would you recommend that this participant be placed at the following types of sites?

Sheltered Internship or In-house Learning Project (requires additional guidance) No restrictions, capable of independently following directions with little guidance Other: Please explain:

Notes: Referral Agency Signature:

Date:

Please complete upon acceptance of Package: Provider Print Last Name: Provider Signature:

Date Rec’d:

Please track all applications submitted and accepted by the provider. Only one (1) application can be submitted per applicant. Submission of an application package is contingent upon the availability of slots with the provider and does not guarantee enrollment.

Name_________________________________________________________________SYEP ID# _____________________

Participant Enrollment Survey (PES) 2020 - OY

NY

STAT

E El

igib

ility

St

atus

A comparison of the information provided in your application with the NYS 200% poverty standards guideline has been completed to certify your eligibility for NY STATE Services. Based on those findings: The applicant is certified for NY STATE Services. (Please initial below in the participant and the Parent /Legal Guardian) By initialing this, I am swearing, under penalty of perjury, that all of the enclosed information is true to the best of my knowledge and that I am willing to cooperate with any efforts to verify the information provided. Participant

Initials Parent /Guardian

Initials

1. Social Security Number (Please be accurate)

- -

2. Last Name 3. First Name 4. MI

5. Birth Date (MM/DD/YYYY) 6. Gender (Check one) 7. Citizenship Status (Check one)

/ / Male Female U.S. Citizen Permanent Resident Alien

Other

8. Selective Service Registration # & Date- Males 18 years of age must be registered with the Selective Service System to participate in the program (if you have not already registered; visit www.sss.gov .)

9.

Alien Number:

# - - Date / / USCIS Form #:

10. Street Address (Number and Street) 11. Apt. 12. Zip Code

13. Do you live in a NYCHA Housing Development?

No

If No; Go to question 14.

Yes If Yes, Name the Development:

14. Borough (Check One) Bronx Brooklyn Manhattan Queens Staten Island

15. Applicant’s Ethnicity (Select One) Hispanic or Latino Not Hispanic or Latino

16. Applicant Race (Select One) Black or African American American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Asian White or Caucasian Other

17. Other than English, what Albanian Arabic Bengali Chinese (incl. Cantonese & Mandarin) French

Language are you most Fulani German Greek Gujarati Haitian Creole Comfortable speaking? Hebrew Hindi Hungarian Italian Japanese (Check all that apply) Korean Kru, Ibo or Yoruba Mande Punjabi Persian Polish Portuguese Romanian Russian Spanish Tagalog Turkish Urdu Vietnamese Yiddish Other (Describe): _________________

18.

Applicant’s Home Phone #

19.

Applicant’s Cell Phone #

20.

Applicant’s Email

-

-

-

-

21. Last Name of Parent/Legal Guardian if Participant is under 18

22. First Name of Parent/Legal Guardian if Participant is under 18

23. Emergency Contact Phone #

-

-

Educational Status 24. Education – Student Type Currently Attending School Not in-school 25. Current Educational Status J.H.S grade 6th 7th 8th H.S. grade 9th 10th 11th 12th College Freshman Junior Sophomore Senior 26. Please indicate the school system you attend DOE CUNY Other a. What school did/do you attend? b. Indicate last grade completed.

Grade 0 - 8 High School Graduate/ HSE Grade 9-11 12+ Some Post-Secondary 2 or 4 year College Graduate

Income & Other Information

27. Total family income (gross) for the last SIX months $

28. Number of family members currently living in applicant’s household

a. Type of Applicant Household

Single Parent Female

Two Adults-No Children

Single Person – No Children

Single Parent Male

Two Parent Home Other

29.

Is applicant or applicant’s family currently receiving public assistance? Yes No (Skip to #31)

30. Type of Public Assistance (Check all that apply)

Family Assistance (formerly known as AFDC)

S.S.I.

Supplemental Nutrition Assistance Program (SNAP)

Safety Net/Home Relief

Other _____________________

31. Is the applicant any of the following (Check all that apply) Disabled Offender/Justice Involved Served in the Military Foster Care ACS Preventative Services Does Not Apply

Homeless/Runaway Parent

One application will be accepted for each applicant. Completed applications will be entered into a lottery to determine those applicants who will be offered a position in the Summer Youth Employment Program. SUBMISSION OF AN APPLICATION DOES NOT GUARANTEE ELIGIBILITY OR ENROLLMENT INTO THE PROGRAM. By submitting your application to DYCD, you acknowledge that information provided in this application and during any participation in the program may be used by the City of New York to evaluate and improve City services and programs or to access additional funding. Answers to the following application items are voluntary and will be treated with confidentiality: Spoken Language, Disability Status. Answers to these questions cannot be used to affect your status in receiving employment, benefits and/or services.

http://www.sss.gov/

Name_________________________________________________________________SYEP ID# _____________________


33. Favorite Subject: Least Favorite Subject:

34. What is your current grade average? 34a. What is your major (potential) in college?

35. If educated outside of the U.S., comparable grade level:

Employment History & Goals

36. Work History: (Give a brief overview of the types of jobs you have held in the past.)

37. Has participant made informed job choices in the past? Yes No

38. Does participant possess appropriate labor market information? Yes No

39. List three work related skills you possess:

a. b. c.

40. What career interests has the participant expressed? (Check all appropriate categories.)

Creative Arts Mechanical Financial Science

Industrial Human Services Medical Business Administration

Food Services Protective Services Athletics Law

Retail Technology Education Skilled Trades

Other (Specify):

41. What is the applicant’s long-term career goal?

42. Have you set a savings goal for the summer? Yes (Go to a.) No Don’t Know Does not want to disclose a. How much of your salary do you plan to save this summer? $

Health Questionnaire THIS SECTION MUST BE COMPLETED AND SIGNED BY PARTICIPANT (AND PARENT/GUARDIAN IF YOUTH IS UNDER 18).

43. Do you have any allergies, e.g. asthma, hay fever, penicillin, dust, etc.? Yes (please list) No 44. Are you presently taking any medication that you would like us to know about in case of

emergency? Yes (please list) No

45. Do you have any illness, injury or on-going medical condition which would prevent you from

performing specific tasks at the Worksite? Yes (please explain) No

32. School History: (Ask the participant to discuss the schools they have attended in the past and why they left.

SCHOOL(S) ATTENDED FROM TO REASON FOR LEAVING COMMENTS (Note if Alternative School)

Consent for Emergency Medical Treatment – complete if youth is under 18

I, _______________________________________, the parent/guardian of ___________________________________ do hereby give authorization to the staff of the SYEP Provider or the Worksite supervisor to obtain emergency medical treatment for my child if s/he is injured or requires medical attention in my absence with the understanding that the family will be notified as soon as possible.

Participant Signature Date Parent/Guardian Signature Date

Consent for Emergency Medical Treatment – complete if youth is 18 or over

I, _______________________________________, do hereby give authorization to the staff of the SYEP Provider or the Worksite supervisor to obtain emergency medical treatment for me if I am injured or require medical attention with the understanding that my emergency contact will be notified as soon as possible.

Participant Signature Date

Name_________________________________________________________________SYEP ID# _____________________


Maximum Hours & Unpaid Orientation Acknowledgment Youth enrolled in subsidized jobs may participate in Summer Youth Employment Program activities a maximum of 25 hours per week. Additionally, youth must complete an unpaid orientation prior to beginning employment activities. The orientation will be delivered in two parts: in person by the provider and online by using a digital platform. By initialing this section the participant (and the parent if Participant is under 18) fully understand that participation in SYEP activities, and payment for those activities, is limited to the applicable maximum number of hours per week and participant must complete all unpaid orientation hours, as required both in-person and on the digital platform, prior to engaging in employment activities.

Participant Initials

Parent/Guardian Initials (if Participant is under 18)

Participant Pay Card Acknowledgment I acknowledge that I have a choice of payment methods for my payroll. I may choose to be paid by debit card issued by MetaBank at 5501 South Broadband Lane, Sioux Falls, SD 57108 or direct deposit into an existing bank account. I understand that I may make my selection in accordance with the enrollment procedures set forth for the Summer Youth Employment Program. If I do not complete a selection of payment method by the due date disclosed within the enrollment procedures, I understand that I shall be paid by debit card and agree to be so paid. By initialing this section the participant (and the parent if Participant is under 18) agree they acknowledge the terms stated above as it pertains to their payment options.



Photo/Video Release Waiver I hereby authorize and permit the City of New York Department of Youth and Community Development (“DYCD”) or its authorized agent, without compensation therefore, permission to photograph, publish, reproduce, record and use, with or without my name or the name of the person for whom I am the parent/guardian. This includes, but is not limited to, photographs, quotes and/or text, motion pictures, videotapes, Web site pages and personal stories or audio tapes of and/or by me or the person for whom I am the parent/guardian.

I release DYCD from any and all legal liability that may arise from the release of information requested. I agree that all text, Web information/hypertext, photographs, motion pictures, negatives, prints and transparencies, videotapes and audio tapes made of and/ or by me or the person for whom I am the parent/guardian by or for DYCD, shall be the exclusive property of DYCD, which in its sole discretion may use this material as it sees fit in any medium or forum. By initialing this section the participant (and the parent if Participant is under 18) agree to the Photo/Video terms stated above. If you do not agree to these terms, please mark this/these box(es) N/A.



CERTIFICATION STATEMENT I, the undersigned, certify that all information on this form is true and correct. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under both New York State Penal Laws, section 175.35 and Federal Law, 18 U.S.C.A. 1001, and to civil action for return of all monies received. I acknowledge that information I have provided in this application and during Participant’s participation in the program may be used by the City of New York to evaluate and improve City services and programs or to access additional funding. I agree and accept that I (and my child if I am signing on their behalf), will abide by all applicable rules and regulations of this program.

Thank you for your participation and Good Luck in the Summer Youth Employment Program.

Participant Signature Date Intake Officer Signature Date

Parent/Guardian Signature (Must be signed if Participant is under 18 or Participant has entered Parent/Guardian income information in Question #27 above.)

Date

Special Initiative: Participant Data Analysis Questions 2020

Application Information for SYEP Application: Part 2

Please complete the following questions:

Applicant Signature _____________________________________________ Date ______________

32. Prior work experience? (paid or volunteer) Yes No 33. What is the applicant’s long-term career goal? List three (3) options:

1st

2nd

3rd

34. Do you have a bank account? Yes No

35. Interested in opening a bank account? Yes No

36. Interested in direct deposit? Yes No

37.

Is the applicant or any member of the household (0-64 years of age) covered by Medicaid, Child Health Plus, Family Health Plus or private medical insurance? Yes No

38. If NO, do you want to be contacted with information about public health insurance programs? Yes No

If you are selected from the lottery or recruited for a summer opportunity, you will need to bring certain documents to your SYEPprovider. You must submit COPIES of one (1) item from categories 1-9 listed below as it applies to you. These items are needed toofficially complete your enrollment so that you are eligible for SYEP. Note that some documents may satisfy more than onecategory (e.g. U.S. Birth Certificate or current U.S. Passport for categories 2 and 7).

1. Proof of Identity

Official Picture ID(school, city, state, government issued)IDNYC Municipal ID will be accepted

2. Proof of Age

Birth Certificate OR

Benefit Card OR

NYS Driver/Non-Driver’s License OR

Alien Registration Card OR

Valid U.S. Passport

3. Proof of Social Security Number

Social Security Card (ONLY)

4. Proof of Address (Dated within the last 6 months)

Home Utility Bill OR

Current Lease, Mortgage, Deed OR

Current Cable Bill (Must have Phone ServiceListed) OR

Official Mail from a Federal, State or City Agency

8. Proof of Family Income(Dated within the last 6 months)

If Supported by Public Assistance

Current EBT Card (with parent/guardian name)AND a recent store receipt OR

Current Benefit Budget/SNAP Letter OR

Official letter from Social Services (Must includeapplicant’s name, Benefit # and date)

OR

If Not Supported by Public Assistance

Two (2) consecutive pay stubs dated within thelast six months (Must include payee name, and grossincome) OR

2019 W-2 form and one (1) pay stub dated withinthe last six months OR

Current Pension Award letter OR

Current SSA Award letter OR

Unemployment Benefit Document dated withinthe last six months OR

If self-employed, 2019 Tax Return includingSchedule “C” or “E” (if receiving rental income)

5.SYEP Application

A signed SYEP application is required for allyouth. Youth under the age of 18 are required tohave the signature of a parent or guardian.

6. Proof of Employment Authorization

Report Card (dated within the last 6 mos ) OR

Official School Transcript OR

NYS Driver/Non-Driver’s License OR

Voter’s Registration Card OR

U.S. Military Card /Draft Record OR

9. Working Papers (Must be age applicable)

Working papers can be acquired through yourschool. If you are not attending school, call 311 orcontact your local District Office.

Required for Youth under 18 years of age ONLY16 and 17 years of age: Green Card

10. Please provide ONLY if applicable

Selective Service Registration Card ORSelective Service “Online Receipt”Required for males 18 years of age or older

7. Proof of Citizenship/Alien Status

Valid U.S. Passport OR

U.S. Birth Certificate OR

Alien Registration Card OR

I-94 , I-551, I-797 OR

Certificate of Naturalization OR

Employment Registration Card

Proof of Disability: Official documentation asapplicable certifying disability from a physician,ACS, HRA, School, Social Service agency orauthorized entity.

Please note: all references to the word current meandocuments dated within the last six (6) months orwhere applicable, documents which are still validand have not expired. The status of your applicationcan be found at www.nyc.gov/dycd.

Summer Youth Employment Program (SYEP)Required Document Checklist: OLDER YOUTH

(16-24 Years Old)

Reminder: ONLY COPIES OF THESE DOCUMENTS WILL BE ACCEPTED

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form W-4 Department of the Treasury Internal Revenue Service

Employee’s Withholding Certificate ▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

▶ Give Form W-4 to your employer. ▶ Your withholding is subject to review by the IRS.

OMB No. 1545-0074

2020 Step 1: Enter Personal Information

(a) First name and middle initial Last name (b) Social security number

Address ▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

City or town, state, and ZIP code

(c) Single or Married filing separately Married filing jointly (or Qualifying widow(er)) Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following. (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option

is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ......................... ▶

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3: If your income will be $200,000 or less ($400,000 or less if married filing jointly): Claim Dependents Multiply the number of qualifying children under age 17 by $2,000 ▶ $

Multiply the number of other dependents by $500 ...................... ▶ $

Add the amounts above and enter the total here . . . . . . . . . . . . .

3

$

Step 4 (a) Other income (not from jobs). If you want tax withheld for other income you expect (optional): this year that won’t have withholding, enter the amount of other income here. This may

Other include interest, dividends, and retirement income . . . . . . . . . . . .

Adjustments (b) Deductions. If you expect to claim deductions other than the standard deduction

and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . .

(c) Extra withholding. Enter any additional tax you want withheld each pay period .

4(a)

$

4(b)

$

4(c)

$

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) Date

Employers Only

Employer identification number (EIN)

First date of employment

Employer’s name and address

▲

▲

http://www.ssa.gov/

http://www.irs.gov/W4App

Page 2 Form W-4 (2020)

General Instructions Future Developments For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505. Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021. Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year). When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you: 1. Expect to work only part of the year; 2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax; 3. Have self-employment income (see below); or 4. Prefer the most accurate withholding for multiple job situations. Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding. Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.

Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return. Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

CAUTION ▲!

http://www.irs.gov/FormW4




If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1 Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the “Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and

2c below. Otherwise, skip to line 3.

a Find the amount from the appropriate table on page 4 using the annual wages from the highest

paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $

b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the

wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b $

c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c $

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays

weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $

1 Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such

deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . . . 1 $

Enter: • $18,650 if you’re head of household

• $12,400 if you’re single or married filing separately

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is

subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Step 4(b)—Deductions Worksheet (Keep for your records.)

Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

2 { • $24,800 if you’re married filing jointly or qualifying widow(er) }

. . . . . . . .

2

$

3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . .

3

$

4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information

4

$

5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $



Married Filing Jointly or Qualifying Widow(er) Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary

Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870 $10,000 - 19,999 220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070 $20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900 $30,000 - 39,999 900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100 $40,000 - 49,999 1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220 $50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220 $60,000 - 69,999 1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220 $70,000 - 79,999 1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240 $80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460

$100,000 - 149,999 1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180 $150,000 - 239,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250 $240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170 $260,000 - 279,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770 $280,000 - 299,999 2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370 $300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970 $320,000 - 364,999 2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840 $365,000 - 524,999 2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280 $525,000 and over 3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650

Single or Married Filing Separately Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary


$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040 $10,000 - 19,999 940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830 $20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110 $30,000 - 39,999 1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310 $40,000 - 59,999 1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080 $60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060 $80,000 - 99,999 2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060

$100,000 - 124,999 2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620 $125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370 $150,000 - 174,999 2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120 $175,000 - 199,999 2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230 $200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930 $250,000 - 399,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930 $400,000 - 449,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540 $450,000 and over 3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300

Head of Household Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary


$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040 $10,000 - 19,999 830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440 $20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850 $30,000 - 39,999 1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140 $40,000 - 59,999 1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360 $60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380 $80,000 - 99,999 1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380

$100,000 - 124,999 2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870 $125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620 $150,000 - 174,999 2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370 $175,000 - 199,999 2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980 $200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870 $250,000 - 349,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870 $350,000 - 449,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200 $450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240

First name and middle initial Last name Your Social Security number

Permanent home address (number and street or rural route) Apartment number

City,village,orpostoffice State ZIPcode

Are you a resident of New York City? ........... Yes NoAre you a resident of Yonkers? ..................... Yes NoComplete the worksheet on page 4 before making any entries.1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 20) ........... 12 Total number of allowances for New York City (from line 35) .................................................................................. 2

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York State amount ........................................................................................................................................ 34 New York City amount ........................................................................................................................................... 45 Yonkers amount .................................................................................................................................................... 5

Department of Taxation and Finance

Employee’s Withholding Allowance CertificateNew York State • New York City • Yonkers

Single or Head of household Married

Married, but withhold at higher single rate

Note:Ifmarriedbutlegallyseparated,markanX in the Single or Head of household box.

IcertifythatIamentitledtothenumberofwithholdingallowancesclaimedonthiscertificate.Employee’s signature Date

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.) Employeridentificationnumber

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Changes effective for 2020FormIT-2104hasbeenrevisedfortaxyear2020.Theworksheetonpage4andthechartsbeginningonpage5,usedtocomputewithholdingallowancesortoenteranadditionaldollaramountonline(s)3,4,or5,havebeenrevised.IfyoupreviouslyfiledaFormIT-2104andusedtheworksheetorcharts,youshouldcompleteanew2020FormIT-2104andgive it to your employer.

Who should file this form Thiscertificate,FormIT-2104,iscompletedbyanemployeeandgivento the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

IfthefederalFormW-4youmostrecentlysubmittedtoyouremployerwasfortaxyear2019orearlier,andyoudonotfileFormIT-2104,youremployer may use the same number of allowances you claimed on your federalFormW-4.Duetodifferencesintaxlaw,thismayresultinthewrong amount of tax withheld for New York State, New York City, and Yonkers.

Fortaxyears2020orlater,withholdingallowancesarenolongerreportedonfederalFormW-4.Therefore,ifyousubmitafederalFormW-4toyour

employerfortaxyear2020orlater,andyoudonotfileFormIT-2104,youremployer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

CompleteFormIT-2104eachyearandfileitwithyouremployerifthenumberofallowancesyoumayclaimisdifferentfromfederalFormW-4orhaschanged.CommonreasonsforcompletinganewFormIT-2104eachyear include the following:

• You started a new job.• You are no longer a dependent.• Your individual circumstances may have changed (for example, you

were married or have an additional child).• You moved into or out of NYC or Yonkers.• You itemize your deductions on your personal income tax return.• You claim allowances for New York State credits.• Youowedtaxorreceivedalargerefundwhenyoufiledyourpersonal

income tax return for the past year.• Yourwageshaveincreasedandyouexpecttoearn$107,650ormore

during the tax year.

Instructions

Employer: Keep this certificate with your records.Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A Employeeclaimedmorethan14exemptionallowancesforNYS ............ A

B Employee is a new hire or a rehire ... B First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Aredependenthealthinsurancebenefitsavailableforthisemployee? ............. Yes No

IfYes,enterthedatetheemployeequalifies(mm-dd-yyyy):

IT-2104

Page 2 of 8 IT-2104(2020)

• Thetotalincomeofyouandyourspousehasincreasedto$107,650ormore for the tax year.

• Youhavesignificantlymoreorlessincomefromothersourcesorfromanother job.

• You no longer qualify for exemption from withholding.• YouhavebeenadvisedbytheInternalRevenueServicethatyou

are entitled to fewer allowances than claimed on your original federal FormW-4(submittedtoyouremployerfortaxyear2019orearlier),and the disallowed allowances were claimed on your original FormIT-2104.

• You are a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program.

• You made contributions to a New York Charitable Gifts Trust Fund (the Health Charitable Account or the Elementary and Secondary Education Account).

Exemption from withholdingYoucannotuseFormIT-2104toclaimexemptionfromwithholding.To claim exemption from income tax withholding, you mustfileFormIT-2104-E,Certificate of Exemption from Withholding, with your employer.Youmustfileanewcertificateeachyearthatyouqualifyforexemption. This exemption from withholding is allowable only if you had no New York income tax liability in the prior year, you expect none in the current year, andyouareover65yearsofage,under18,orafull-timestudentunder25.Youmayalsoclaimexemptionfromwithholdingifyou are a military spouse and meet the conditions set forth under the ServicemembersCivilReliefActasamendedbytheMilitarySpousesResidencyReliefActandtheVeteransBenefitsandTransitionAct.Ifyouareadependentwhoisunder18orafull-timestudent,youmayowetaxifyourincomeismorethan$3,100.

Withholding allowancesYou may not claim a withholding allowance for yourself or, if married, your spouse. Claim the number of withholding allowances you compute inPart1andPart5oftheworksheetonpage4.Ifyouwantmoretaxwithheld, you may claim fewer allowances. If you claim more than 14 allowances, your employer must send a copy of your Form IT-2104 to the New York State Tax Department. You may then be asked to verifyyourallowances.Ifyouarriveatnegativeallowances(lessthanzero)onlines1or2andyouremployercannotaccommodatenegativeallowances, enter 0 and see Additional dollar amount(s) below.

Income from sources other than wages –Ifyouhavemorethan$1,000ofincomefromsourcesotherthanwages(suchasinterest,dividends, or alimony received), reduce the number of allowances claimedonline1andline2(ifapplicable)oftheIT-2104certificatebyoneforeach$1,000ofnonwageincome.Ifyouarriveatnegativeallowances (less than zero), see Withholding allowances above. You may also consider making estimated tax payments, especially if you havesignificantamountsofnonwageincome.Estimatedtaxrequiresthat payments be made by the employee directly to the Tax Department on a quarterly basis. For more information, see the instructions for FormIT-2105,Estimated Tax Payment Voucher for Individuals, or see Need help?onpage7.

Other credits (Worksheetline14) – Ifyouwillbeeligibletoclaimany credits other than the credits listed in the worksheet, such as an investment tax credit, you may claim additional allowances.

FindyourfilingstatusandyourNewYorkadjustedgrossincome(NYAGI)in the chart below, and divide the amount of the expected credit by the number indicated. Enter the result (rounded to the nearest whole number) online14.

Single and NYAGI is:

Head of household and NYAGI is:

Married and NYAGI is:

Divide amount of expected credit by:

Less than Less than Less than 65 $215,400 $269,300 $323,200 Between Between Between $215,400and $269,300and $323,200and 68 $1,077,550 $1,616,450 $2,155,350 Over Over Over 88 $1,077,550 $1,616,450 $2,155,350

Example: You are married and expect your New York adjusted gross income to be less than $323,200. In addition, you expect to receive a flow-through of an investment tax credit from the S corporation of which

you are a shareholder. The investment tax credit will be $160. Divide the expected credit by 65. 160/65 = 2.4615. The additional withholding allowance(s) would be 2. Enter 2 on line 14.

Married couples with both spouses working –Ifyouandyourspousebothwork,youshouldeachfileaseparateIT-2104certificatewithyourrespective employers. Your withholding will better match your total tax if thehigherwage-earningspouseclaimsallofthecouple’sallowancesandthelowerwage-earningspouseclaimszeroallowances.Do not claim moretotalallowancesthanyouareentitledto.Ifyourcombinedwagesare: • lessthan$107,650,youshouldeachmarkanX in the box Married,

but withhold at higher single rateonthecertificatefront,anddividethetotalnumberofallowancesthatyoucomputeonline20andline35(ifapplicable) between you and your working spouse.

• $107,650ormore,usethechart(s)inPart6andentertheadditionalwithholding dollar amount on line 3.

Taxpayers with more than one job –Ifyouhavemorethanonejob,fileaseparateIT-2104certificatewitheachofyouremployers.Besure to claim only the total number of allowances that you are entitled to. Your withholding will better match your total tax if you claim all of yourallowancesatyourhigher-payingjobandzeroallowancesatthelower-payingjob.Inaddition,tomakesurethatyouhaveenoughtax withheld, if you are a single taxpayer or head of household with two or more jobs, and your combined wages from all jobs are under $107,650,reducethenumberofallowancesbysevenonline1andline2(ifapplicable)onthecertificateyoufilewithyourhigher-payingjobemployer.Ifyouarriveatnegativeallowances(lessthanzero),see Withholding allowances above.

Ifyouareasingleoraheadofhouseholdtaxpayer,andyourcombinedwagesfromallofyourjobsarebetween$107,650and$2,263,265,usethechart(s)inPart7andentertheadditionalwithholdingdollaramountfrom the chart on line 3.

Ifyouareamarriedtaxpayer,andyourcombinedwagesfromallofyourjobsare$107,650ormore,usethechart(s)inPart6andentertheadditional withholding dollar amount from the chart on line 3 (Substitute the words Higher-paying job for Higher earner’s wages within the chart).

Dependents – Ifyouareadependentofanothertaxpayerandexpectyourincometoexceed$3,100,youshouldreduceyourwithholdingallowancesbyoneforeach$1,000ofincomeover$2,500.Thiswillensure that your employer withholds enough tax.

Following the above instructions will help to ensure that you will not owe additionaltaxwhenyoufileyourreturn.

Heads of households with only one job – Ifyouwillusethehead-of-householdfilingstatusonyourstateincometaxreturn,markthe Single or Head of householdboxonthefrontofthecertificate.Ifyouhave only one job, you may also wish to claim two additional withholding allowancesonline15.

Additional dollar amount(s)You may ask your employer to withhold an additional dollar amount each payperiodbycompletinglines3,4,and5onFormIT-2104.Inmostinstances, if you compute a negative number of allowances and your employer cannot accommodate a negative number, for each negative allowanceclaimedyoushouldhaveanadditional$1.85oftaxwithheldperweek for New York State withholding on line 3, and an additional $0.80 oftaxwithheldperweekforNewYorkCitywithholdingonline4.Yonkersresidentsshoulduse16.75%(.1675)oftheNewYorkStateamountforadditional withholding for Yonkers on line 5.

Note:Ifyouarerequestingyouremployertowithholdanadditionaldollaramountonlines3,4,or5ofthisallowancecertificate,theadditionaldollar amount, as determined by these instructions or by using the chart(s)inPart6orPart7,isaccurateforaweeklypayroll.Therefore,if you are not paid on a weekly basis, you will need to adjust the dollar amount(s) that you compute. For example, if you are paid biweekly, you must double the dollar amount(s) computed.

Avoid underwithholdingFormIT-2104,togetherwithyouremployer’swithholdingtables,isdesigned to ensure that the correct amount of tax is withheld from your pay. Ifyoufailtohaveenoughtaxwithheldduringtheentireyear,youmayowealargetaxliabilitywhenyoufileyourreturn.TheTaxDepartmentmustassess interest and may impose penalties in certain situations in addition tothetaxliability.Evenifyoudonotfileareturn,wemaydetermine

IT-2104 (2020) Page 3 of 8

that you owe personal income tax, and we may assess interest and penalties on the amount of tax that you should have paid during the year.

EmployersBox A – Ifyouarerequiredtosubmitacopyofanemployee’sFormIT-2104totheTaxDepartmentbecausetheemployeeclaimedmorethan14allowances,markanX in box A and send a copy ofFormIT-2104to:NYS Tax Department, Income Tax Audit Administrator, Withholding Certificate Coordinator, W A Harriman Campus, Albany NY 12227-0865.Iftheemployeeisalsoanewhireorrehire, see Box B instructions. See Publication 55, Designated Private Delivery Services, if not using U.S. Mail.

Duedatesforsendingcertificatesreceivedfromemployeesclaimingmorethan14allowancesare:Quarter Due date Quarter Due dateJanuary–March April30 July–September October31April–June July31 October–December January31

Box B – IfyouaresubmittingacopyofthisformtocomplywithNewYorkState’sNewHireReportingProgram,markanX in box B. Enter the firstdayanyservicesareperformedforwhichtheemployeewillbepaidwages, commissions, tips and any other type of compensation. For servicesbasedsolelyoncommissions,thisisthefirstdayanemployeeworking for commissions is eligible to earn commissions. Also, mark an X in the Yes or Noboxindicatingifdependenthealthinsurancebenefitsareavailabletothisemployee.IfYes,enterthedatetheemployeequalifiesforcoverage.Mailthecompletedform,within20daysofhiring,to:NYS Tax Department, New Hire Notification, PO Box 15119, Albany NY 12212-5119. Toreportnewly-hiredorrehiredemployeesonlineinsteadofsubmitting this form, go to https://www.nynewhire.com.

(continued)

Page 4 of 8 IT-2104 (2020)

WorksheetSee the instructions before completing this worksheet.

Part 1 – Complete this part to compute your withholding allowances for New York State and Yonkers (line1).

Part 5 – Complete this part to compute your withholding allowances for New York City (line2).

Part 3 – Complete this part if you expect to be a covered employee of an employer that has elected to participate in the Employer Compensation Expense Program (line17).

Part 4 – Complete this part if you made contributions in 2019 to the Health Charitable Account or the Elementary and Secondary Education Account (line18).

Part 2 – Complete this part only if you expect to itemize deductions on your state return. 21 Enter your estimated NY itemized deductions for the tax year (see Form IT-196 and its instructions; enter the amount from line 49) 21 22 Basedonyourfederalfilingstatus,entertheapplicableamountfromthetablebelow ............................................................ 22

Single (cannot be claimed as a dependent) .... $ 8,000 Qualifying widow(er) ........................................ $16,050 Single (can be claimed as a dependent) ....... $ 3,100 Marriedfilingjointly .......................................... $16,050 Head of household ......................................... $11,200 Marriedfilingseparatereturns ......................... $ 8,000

23 Subtractline22fromline21(if line 22 is larger than line 21, enter 0 here and on line 19 above) ........................................................ 23 24 Divideline23by$1,000.Dropanyfractionandentertheresulthereandonline19above .................................................... 24

33 Entertheamountfromline6above .......................................................................................................................................... 33 34 Addlines15through19aboveandentertotalhere ................................................................................................................. 34 35 Addlines33and34.Entertheresulthereandonline2 .......................................................................................................... 35

30 Contributionstothesefundsin2019 ........................................................................................................................................ 30 31 Multiplyline30by85%(.85) ..................................................................................................................................................... 31 32 Divideline31by60.Dropanyfractionandentertheresulthereandonline18above ........................................................... 32

25 Expectedannualwagesandcompensationfromelectingemployerin2020 ........................................................................... 25 26 Line25minus$40,000(ifzeroorless,stop) ........................................................................................................................... 26 27 Line26multipliedby.03 ........................................................................................................................................................... 27 28 Line27multipliedby.935 ......................................................................................................................................................... 28 29 Divideline28by65.Dropanyfractionandentertheresulthereandonline17above ........................................................... 29

6 Enter the number of dependents that you will claim on your state return (do not include yourself or, if married, your spouse) ..... 6 For lines 7, 8, and 9, enter 1 for each credit you expect to claim on your state return. 7 College tuition credit .................................................................................................................................................................. 7 8 New York State household credit ............................................................................................................................................... 8 9 Realpropertytaxcredit .............................................................................................................................................................. 9 For lines 10, 11, and 12, enter 3 for each credit you expect to claim on your state return. 10 Child and dependent care credit ............................................................................................................................................... 10 11 Earned income credit ................................................................................................................................................................ 11 12 Empire State child credit ........................................................................................................................................................... 12 13 NewYorkCityschooltaxcredit:IfyouexpecttobearesidentofNewYorkCityforanypartofthetaxyear,enter2 .............. 13 14 Other credits (see instructions) ..................................................................................................................................................... 14 15 Head of household status and only one job (enter 2 if the situation applies) .................................................................................. 15 16 Enteranestimateofyourfederaladjustmentstoincome,suchasdeductibleIRAcontributionsyouwillmakeforthe tax year. Total estimate $ .Dividethisestimateby$1,000.Dropanyfractionandenterthenumber ...... 16 17 Ifyouexpecttobeacoveredemployeeofanemployerwhoelectedtopaytheemployercompensationexpensetaxin 2020,completePart3belowandenterthenumberfromline29 .......................................................................................... 17 18 Ifyoumadecontributionsin2019toaNewYorkCharitableGiftsTrustFund(theHealthCharitableAccountorthe ElementaryandSecondaryEducationAccount),completePart4belowandentertheamountfromline32 ...................... 18 19 Ifyouexpecttoitemizedeductionsonyourstatetaxreturn,completePart2belowandenterthenumberfromline24. All others enter 0 ................................................................................................................................................................... 19 20 Addlines6through19.Entertheresulthereandonline1.Ifyouhavemorethanonejob,orifyouandyourspouseboth work, see instructions for Taxpayers with more than one job or Married couples with both spouses working. ..................... 20

Standard deduction table

IT-2104 (2020) Page 5 of 8

Part 6 – These charts are only for married couples with both spouses working or married couples with one spouse working more than onejob,andwhosecombinedwagesarebetween$107,650and$2,263,265.

Enter the additional withholding dollar amount on line 3.

Theadditionaldollaramount,asshownbelow,isaccurateforaweeklypayroll.Ifyouarenotpaidonaweeklybasis,youwillneedtoadjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.

Combined wages between $107,650 and $538,749Higher earner’s wages

Combined wages between $538,750 and $1,185,399

Higher earner’s wages

$107,650 $129,250 $150,750 $172,300 $193,850 $236,950 $280,100 $323,200 $377,100 $430,950 $484,900 $129,249 $150,749 $172,299 $193,849 $236,949 $280,099 $323,199 $377,099 $430,949 $484,899 $538,749

$53,800 $75,299 $13 $19

$75,300 $96,799 $12 $20 $28 $32

$96,800 $118,399 $8 $17 $24 $32 $39

$118,400 $129,249 $2 $11 $19 $26 $36 $33

$129,250 $139,999 $4 $15 $22 $33 $30

$140,000 $150,749 $2 $11 $18 $29 $30 $25

$150,750 $161,549 $4 $15 $25 $30 $22

$161,550 $172,499 $2 $11 $22 $28 $22 $19

$172,500 $193,849 $4 $16 $23 $22 $29 $30

$193,850 $236,949 $6 $12 $18 $30 $36 $31

$236,950 $280,099 $6 $12 $36 $45 $39 $41

$280,100 $323,199 $6 $30 $53 $47 $41

$323,200 $377,099 $15 $31 $40 $34

$377,100 $430,949 $8 $18 $27

$430,950 $484,899 $8 $18

$484,900 $538,749 $8

$538,750 $592,650 $646,500 $700,400 $754,300 $808,200 $862,050 $915,950 $969,900 $1,023,750 $1,077,550 $1,131,500 $592,649 $646,499 $700,399 $754,299 $808,199 $862,049 $915,949 $969,899 $1,023,749 $1,077,549 $1,131,499 $1,185,399

$236,950 $280,099 $28

$280,100 $323,199 $45 $22

$323,200 $377,099 $28 $33 $37 $22

$377,100 $430,949 $21 $16 $20 $25 $5 $5

$430,950 $484,899 $27 $21 $16 $20 $25 $5 $5 $5

$484,900 $538,749 $18 $27 $21 $16 $20 $25 $5 $5 $5 $5

$538,750 $592,649 $8 $18 $27 $21 $16 $20 $25 $5 $5 $5 $3 $2

$592,650 $646,499 $8 $18 $27 $21 $16 $20 $25 $5 $5 $3 $2

$646,500 $700,399 $8 $18 $27 $21 $16 $20 $25 $5 $3 $2

$700,400 $754,299 $8 $18 $27 $21 $16 $20 $25 $3 $2

$754,300 $808,199 $8 $18 $27 $21 $16 $20 $26 $2

$808,200 $862,049 $8 $18 $27 $21 $16 $22 $29

$862,050 $915,949 $8 $18 $27 $21 $17 $25

$915,950 $969,899 $8 $18 $27 $22 $20

$969,900 $1,023,749 $8 $18 $29 $26

$1,023,750 $1,077,549 $8 $20 $32

$1,077,550 $1,131,499 $9 $21

$1,131,500 $1,185,399 $9

Page 6 of 8 IT-2104 (2020)

Combined wages between $1,185,400 and $1,724,299




Note: These charts do not account for additional withholding in the following instances: • amarriedcouplewithbothspousesworking,whereonespouse’swagesaremorethan$1,131,632butlessthan$2,263,265,andtheother

spouse’swagesarealsomorethan$1,131,632butlessthan$2,263,265; • marriedtaxpayerswithonlyonespouseworking,andthatspouseworksmorethanonejob,withwagesfromeachjobunder$2,263,265,but

combinedwagesfromalljobsisover$2,263,265.Ifyouareinoneofthesesituationsandyouwouldliketorequestanadditionaldollaramountofwithholdingfromyourwages,pleasecontacttheTax

Department for assistance (see Need help?onpage7).

$1,185,400 $1,239,250 $1,293,200 $1,347,050 $1,400,950 $1,454,850 $1,508,700 $1,562,550 $1,616,450 $1,670,400 $1,239,249 $1,293,199 $1,347,049 $1,400,949 $1,454,849 $1,508,699 $1,562,549 $1,616,449 $1,670,399 $1,724,299

$592,650 $646,499 $5 $8

$646,500 $700,399 $5 $8 $11 $14

$700,400 $754,299 $5 $8 $11 $14 $18 $21

$754,300 $808,199 $5 $8 $11 $14 $18 $21 $24 $27

$808,200 $862,049 $5 $8 $11 $14 $18 $21 $24 $27 $30 $33

$862,050 $915,949 $32 $8 $11 $14 $18 $21 $24 $27 $30 $33

$915,950 $969,899 $28 $36 $11 $14 $18 $21 $24 $27 $30 $33

$969,900 $1,023,749 $23 $31 $39 $14 $18 $21 $24 $27 $30 $33

$1,023,750 $1,077,549 $29 $26 $34 $42 $18 $21 $24 $27 $30 $33

$1,077,550 $1,131,499 $33 $30 $28 $36 $43 $19 $22 $25 $28 $32

$1,131,500 $1,185,399 $21 $33 $30 $28 $36 $43 $19 $22 $25 $28

$1,185,400 $1,239,249 $9 $21 $33 $30 $28 $36 $43 $19 $22 $25

$1,239,250 $1,293,199 $9 $21 $33 $30 $28 $36 $43 $19 $22

$1,293,200 $1,347,049 $9 $21 $33 $30 $28 $36 $43 $19

$1,347,050 $1,400,949 $9 $21 $33 $30 $28 $36 $43

$1,400,950 $1,454,849 $9 $21 $33 $30 $28 $36

$1,454,850 $1,508,699 $9 $21 $33 $30 $28

$1,508,700 $1,562,549 $9 $21 $33 $30

$1,562,550 $1,616,449 $9 $21 $33

$1,616,450 $1,670,399 $9 $21

$1,670,400 $1,724,299 $9

$1,724,300 $1,778,150 $1,832,050 $1,885,950 $1,939,800 $1,993,700 $2,047,600 $2,101,500 $2,155,350 $2,209,300 $1,778,149 $1,832,049 $1,885,949 $1,939,799 $1,993,699 $2,047,599 $2,101,499 $2,155,349 $2,209,299 $2,263,265

$862,050 $915,949 $36 $39

$915,950 $969,899 $36 $39 $42 $46

$969,900 $1,023,749 $36 $39 $42 $46 $49 $52

$1,023,750 $1,077,549 $36 $39 $42 $46 $49 $52 $55 $58

$1,077,550 $1,131,499 $35 $38 $41 $44 $47 $50 $53 $56 $490 $906

$1,131,500 $1,185,399 $32 $35 $38 $41 $44 $47 $50 $53 $487 $906

$1,185,400 $1,239,249 $28 $32 $35 $38 $41 $44 $47 $50 $484 $903

$1,239,250 $1,293,199 $25 $28 $32 $35 $38 $41 $44 $47 $481 $900

$1,293,200 $1,347,049 $22 $25 $28 $32 $35 $38 $41 $44 $477 $897

$1,347,050 $1,400,949 $19 $22 $25 $28 $32 $35 $38 $41 $474 $894

$1,400,950 $1,454,849 $43 $19 $22 $25 $28 $32 $35 $38 $471 $891

$1,454,850 $1,508,699 $36 $43 $19 $22 $25 $28 $32 $35 $468 $888

$1,508,700 $1,562,549 $28 $36 $43 $19 $22 $25 $28 $32 $465 $885

$1,562,550 $1,616,449 $30 $28 $36 $43 $19 $22 $25 $28 $462 $881

$1,616,450 $1,670,399 $33 $30 $28 $36 $43 $19 $22 $25 $459 $878

$1,670,400 $1,724,299 $21 $33 $30 $28 $36 $43 $19 $22 $456 $875

$1,724,300 $1,778,149 $9 $21 $33 $30 $28 $36 $43 $19 $453 $872

$1,778,150 $1,832,049 $9 $21 $33 $30 $28 $36 $43 $449 $869

$1,832,050 $1,885,949 $9 $21 $33 $30 $28 $36 $474 $866

$1,885,950 $1,939,799 $9 $21 $33 $30 $28 $466 $890

$1,939,800 $1,993,699 $9 $21 $33 $30 $458 $882

$1,993,700 $2,047,599 $9 $21 $33 $461 $875

$2,047,600 $2,101,499 $9 $21 $464 $877

$2,101,500 $2,155,349 $9 $451 $880

$2,155,350 $2,209,299 $235 $438

$2,209,300 $2,263,265 $14

IT-2104 (2020) Page 7 of 8

Combined wages between $107,650 and $538,749Higher wage

$538,750 $592,650 $646,500 $700,400 $754,300 $808,200 $862,050 $915,950 $969,900 $1,023,750 $1,077,550 $1,131,500 $592,649 $646,499 $700,399 $754,299 $808,199 $862,049 $915,949 $969,899 $1,023,749 $1,077,549 $1,131,499 $1,185,399

$236,950 $280,099 $9

$280,100 $323,199 $9 $8

$323,200 $377,099 $26 $8 $8 $8

$377,100 $430,949 $22 $26 $8 $8 $8 $8

$430,950 $484,899 $27 $22 $26 $8 $8 $8 $8 $8

$484,900 $538,749 $18 $27 $22 $26 $8 $8 $8 $8 $8 $8

$538,750 $592,649 $8 $18 $27 $22 $26 $8 $8 $8 $8 $8 $236 $451

$592,650 $646,499 $8 $18 $27 $22 $26 $8 $8 $8 $8 $236 $451

$646,500 $700,399 $8 $18 $27 $22 $26 $8 $8 $8 $236 $451

$700,400 $754,299 $8 $18 $27 $22 $26 $8 $8 $236 $451

$754,300 $808,199 $8 $18 $27 $22 $26 $8 $236 $451

$808,200 $862,049 $8 $18 $27 $22 $26 $236 $451

$862,050 $915,949 $8 $18 $27 $22 $254 $451

$915,950 $969,899 $8 $18 $27 $250 $470

$969,900 $1,023,749 $8 $18 $255 $465

$1,023,750 $1,077,549 $8 $246 $471

$1,077,550 $1,131,499 $123 $233

$1,131,500 $1,185,399 $14

Combined wages between $538,750 and $1,185,399

Higher wage

Part 7 – These charts are only for single taxpayers and head of household taxpayers with more than one job, and whose combined wagesarebetween$107,650and$2,263,265.

Enter the additional withholding dollar amount on line 3.

Theadditionaldollaramount,asshownbelow,isaccurateforaweeklypayroll.Ifyouarenotpaidonaweeklybasis,youwillneedtoadjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.

(Part 7 continued on page 8)

$107,650 $129,250 $150,750 $172,300 $193,850 $236,950 $280,100 $323,200 $377,100 $430,950 $484,900 $129,249 $150,749 $172,299 $193,849 $236,949 $280,099 $323,199 $377,099 $430,949 $484,899 $538,749

$53,800 $75,299 $13 $18

$75,300 $96,799 $12 $20 $27 $26

$96,800 $118,399 $8 $17 $24 $27 $28

$118,400 $129,249 $2 $11 $18 $21 $26 $35

$129,250 $139,999 $4 $14 $17 $22 $39

$140,000 $150,749 $2 $10 $13 $19 $39 $38

$150,750 $161,549 $3 $10 $15 $38 $36

$161,550 $172,499 $1 $7 $13 $38 $38 $36

$172,500 $193,849 $3 $10 $36 $42 $38 $37

$193,850 $236,949 $11 $31 $44 $42 $42 $25

$236,950 $280,099 $9 $18 $29 $25 $28 $15

$280,100 $323,199 $7 $17 $27 $22 $26

$323,200 $377,099 $8 $18 $27 $22

$377,100 $430,949 $8 $18 $27

$430,950 $484,899 $8 $18

$484,900 $538,749 $8

Privacy notificationSeeourwebsiteorPublication54,Privacy Notification.

Visitourwebsiteatwww.tax.ny.gov• get information and manage your taxes online• check for new online services and features

Telephone assistanceAutomatedincometaxrefundstatus: 518-457-5149PersonalIncomeTaxInformationCenter: 518-457-5181Toorderformsandpublications: 518-457-5431TextTelephone(TTY)orTDD Dial7-1-1forthe equipmentusers NewYorkRelayService

Need help?

Page 8 of 8 IT-2104 (2020)

$1,185,400 $1,239,250 $1,293,200 $1,347,050 $1,400,950 $1,454,850 $1,508,700 $1,562,550 $1,616,450 $1,670,400 $1,239,249 $1,293,199 $1,347,049 $1,400,949 $1,454,849 $1,508,699 $1,562,549 $1,616,449 $1,670,399 $1,724,299

$592,650 $646,499 $475 $498

$646,500 $700,399 $475 $498 $522 $546

$700,400 $754,299 $475 $498 $522 $546 $569 $593

$754,300 $808,199 $475 $498 $522 $546 $569 $593 $616 $640

$808,200 $862,049 $475 $498 $522 $546 $569 $593 $616 $640 $663 $687

$862,050 $915,949 $475 $498 $522 $546 $569 $593 $616 $640 $663 $687

$915,950 $969,899 $475 $498 $522 $546 $569 $593 $616 $640 $663 $687

$969,900 $1,023,749 $493 $498 $522 $546 $569 $593 $616 $640 $663 $687

$1,023,750 $1,077,549 $489 $517 $522 $546 $569 $593 $616 $640 $663 $687

$1,077,550 $1,131,499 $266 $284 $312 $318 $341 $365 $388 $412 $435 $459

$1,131,500 $1,185,399 $42 $74 $92 $120 $126 $149 $173 $196 $220 $243

$1,185,400 $1,239,249 $14 $42 $74 $92 $120 $126 $149 $173 $196 $220

$1,239,250 $1,293,199 $14 $42 $74 $92 $120 $126 $149 $173 $196

$1,293,200 $1,347,049 $14 $42 $74 $92 $120 $126 $149 $173

$1,347,050 $1,400,949 $14 $42 $74 $92 $120 $126 $149

$1,400,950 $1,454,849 $14 $42 $74 $92 $120 $126

$1,454,850 $1,508,699 $14 $42 $74 $92 $120

$1,508,700 $1,562,549 $14 $42 $74 $92

$1,562,550 $1,616,449 $14 $42 $74

$1,616,450 $1,670,399 $14 $42

$1,670,400 $1,724,299 $14


Higher wage

$1,724,300 $1,778,150 $1,832,050 $1,885,950 $1,939,800 $1,993,700 $2,047,600 $2,101,500 $2,155,350 $2,209,300 $1,778,149 $1,832,049 $1,885,949 $1,939,799 $1,993,699 $2,047,599 $2,101,499 $2,155,349 $2,209,299 $2,263,265

$862,050 $915,949 $710 $734

$915,950 $969,899 $710 $734 $757 $781

$969,900 $1,023,749 $710 $734 $757 $781 $804 $828

$1,023,750 $1,077,549 $710 $734 $757 $781 $804 $828 $851 $875

$1,077,550 $1,131,499 $482 $506 $529 $553 $576 $600 $623 $647 $670 $262

$1,131,500 $1,185,399 $267 $290 $314 $337 $361 $384 $408 $431 $455 $478

$1,185,400 $1,239,249 $243 $267 $290 $314 $337 $361 $384 $408 $431 $455

$1,239,250 $1,293,199 $220 $243 $267 $290 $314 $337 $361 $384 $408 $431

$1,293,200 $1,347,049 $196 $220 $243 $267 $290 $314 $337 $361 $384 $408

$1,347,050 $1,400,949 $173 $196 $220 $243 $267 $290 $314 $337 $361 $384

$1,400,950 $1,454,849 $149 $173 $196 $220 $243 $267 $290 $314 $337 $361

$1,454,850 $1,508,699 $126 $149 $173 $196 $220 $243 $267 $290 $314 $337

$1,508,700 $1,562,549 $120 $126 $149 $173 $196 $220 $243 $267 $290 $314

$1,562,550 $1,616,449 $92 $120 $126 $149 $173 $196 $220 $243 $267 $290

$1,616,450 $1,670,399 $74 $92 $120 $126 $149 $173 $196 $220 $243 $267

$1,670,400 $1,724,299 $42 $74 $92 $120 $126 $149 $173 $196 $220 $243

$1,724,300 $1,778,149 $14 $42 $74 $92 $120 $126 $149 $173 $196 $220

$1,778,150 $1,832,049 $14 $42 $74 $92 $120 $126 $149 $173 $196

$1,832,050 $1,885,949 $14 $42 $74 $92 $120 $126 $149 $173

$1,885,950 $1,939,799 $14 $42 $74 $92 $120 $126 $149

$1,939,800 $1,993,699 $14 $42 $74 $92 $120 $126

$1,993,700 $2,047,599 $14 $42 $74 $92 $120

$2,047,600 $2,101,499 $14 $42 $74 $92

$2,101,500 $2,155,349 $14 $42 $74

$2,155,350 $2,209,299 $14 $42

$2,209,300 $2,263,265 $14


Higher wage

AGENCY LETTERHEAD

Date: __________________

Applicant Name: __________________________________________ Applicant DOB: _______________ Applicant Address: _________________________________________ _________________________________________ This letter certifies that (Applicant Name, DOB) is applying to the 2020 Summer Youth Employment

Program (SYEP). The applicant is (please insert relevant agency language i.e. in the care and custody of

Agency Name).

This letter will serve as verification of the applicant’s eligibility for the Special Initiative service option of SYEP. Please note if this box is checked, the applicant is verified as having no income and therefore has entered

$1 on their application. □ If you have any questions, please feel free to contact me at the information below. Sincerely, ____________________________________________ Case Worker/Responsible for Submission Name [Title] [Phone Number] [Email Address] _____________________________________________ Agency Point Person [Title] [Phone Number] [Email Address]

Summer Youth Employment Program 2020 Emerging Leaders Providers

Provider

Boro of

Office First Name Last Name Title Phone Ext Cell Phone

Number Email Address

C.C.M.S.aka Community Counseling &Mediation

Bk Naphtali Aiken Program Director 718-230-5100 122 917-304-6333

[email protected]

Center for Alternative Sentencing Employment Services, Inc.

Bk Filkoski Aleks

Supervisor – Youth Employment Services 212-553-6627 646-335-2508 [email protected]

Henry Street Settlement M Johanna Ramirez Program Director 212-254-3100 3221 [email protected]

Research Foundation of CUNY on behalf of La Guardia Community College

Q Renee Cheatham Director 718-482-5347 347-409-2443

[email protected]

Samuel Field YM & YWHA, INC. aka Central Queens Y

Q Adam Fier

Program Director, WLG / SYEP 718-268-5011 164 347-804-6164

[email protected]

St. Nicks Alliance Corp. Bk Folasade Maddux Youth Employment Director 718-599-9224 36 646-420-1113

[email protected]

The Children's Aid Society Bx Sandino Sanchez Director 917-286-1535 [email protected]

United Activities Unlimited Inc SI Tatiana Arguello

Director of Workforce Development 718-689-4899 718-689-4899

[email protected]

United Activities Unlimited Inc SI Bert Benjamin Program Director 646-373-0122 [email protected]

mailto:[email protected]




Wildcat Service Corporation

Bk Aron Myers

Director of Youth & Young Adult Programs 212-727-4291 914-803-6826 [email protected]
